While the Medicaid expansion may lead to a dramatic rise in emergency room use and hospitalizations for many of the previously uninsured, that increase is largely temporary and should not lead to a dramatic impact on state budgets, according to a new analysis from the UCLA Center for Health Policy Research released Wednesday.

Researchers reviewed two years of claims data from nearly 200,000 Californians who had enrolled in public programs in advance of the expansion of Medi-Cal, the state’s version of Medicaid, in January. These programs were designed to ease the expansion of Medicaid by providing insurance to low-income adults who were not eligible for Medi-Cal at that point but would be when the health law’s expansion went into effect earlier this year.

Researchers then divided the group into four categories, based on the researchers’ assessment of each group’s pent-up demand for health care.

In July, 2011, after being enrolled in California’s Low Income Health Program, the so-called “bridge to reform,” the group with the highest pent-up demand had a rate of costly emergency room visits triple — or more — that of the other groups. But from 2011 to 2013, that high rate dropped by more than two-thirds and has remained “relatively constant,” according to the analysis.

“We were hoping that this would be the case,” said lead author Jerry Kominski, director of the UCLA Center for Health Policy Research, “because we think that that’s what access to care does for low-income individuals … that there’s an additional increase in demand for services and that that demand, or utilization, drops off pretty rapidly.”

Rates of hospitalization for the “highest pent-up demand” group also started high and dropped by almost 80 percent over the two-year period. Curiously, if ER and hospitalization rates were dropping, it’s reasonable that outpatient visits might rise. But that wasn’t the case; the rate of outpatient visits was largely unchanged during the two-year period.

Kominski said that one of the fears of the Medicaid expansion was the potential high cost of low-income patients. He argued that this analysis should ease those fears. “What our findings say to the country is (that) concerns about Medicaid expansion being financially unsustainable into the future are unfounded.” Under the Affordable Care Act, the federal government provides 100 percent of the cost of the newly eligible under the Medicaid expansion, but in 2017 that contribution will phase down until it reaches 90 percent in 2020.

Twenty-seven states have implemented the Medicaid expansion; 21 have not, and in two states, Indiana and Utah, the question of expansion is an “open discussion,” according to a tally from the Kaiser Family Foundation.

Matt Salo, executive director of the National Association of Medicaid Directors, said the study was “certainly consistent with what we hope to do” by expanding health insurance access. He said insurance is “just the first step, the next step is health care homes so that the individual can actually get better care.”

One factor in helping drive down the higher rates of utilization, Kominski said, is coordinated care initiatives in place for Medi-Cal beneficiaries. For example, virtually all Medi-Cal beneficiaries are now enrolled into a Medi-Cal managed care plan. “To the extent that other states don’t have adequate coordinated care mechanisms in place for their Medicaid populations, then the kinds of drop off that we observed in California may not occur there,” Kominski said.

The UCLA analysis makes explicit reference to — and rebuts — a similar study, the Oregon Health Insurance Experiment. In Oregon in 2008, 10,000 residents literally won Medicaid coverage in a lottery, creating a true randomized controlled trial opportunity for researchers who compared those who won coverage with those who didn’t, rarely possible to do in social policy research. Researchers later reported a 40 percent increase in ER visits in the 18-months after that expansion.

Kate Baicker, a health economist at the Harvard School of Public Health, was one of the researchers in the Oregon experiment. She said they did not find “any evidence of utilization tailing off over that 18-month window” and stands by her results.

Still, Baicker said that an increase in use of health care services, such as emergency room visits or hospitalizations, “does not mean that Medicaid should not be expanded. Part of the goal is to increase access to health care.”

The UCLA study was funded by the California Department of Health Care Services and Blue Shield of California Foundation.

A long-awaited and much-feared ten percent rate cut goes into effect Thursday for doctors and clinics reimbursed through Medi-Cal –- the state’s health insurance for low-income patients. This comes at the same time the federal health overhaul is expanding that program to as many as 2 million Californians.

Provisions of the Affordable Care Act will protect primary care doctors from the cuts for the next two years, but specialty doctors that treat the poor are bracing for the hit. Many physicians in dermatology, neurology, cardiology, and urology will now be losing money on every Medi-Cal patient they see. Some will have no choice but to turn low-income patients away.

“Bottom line, they cannot continue to provide care for below the cost of care,” says Shannon Smith-Crowley, a lobbyist who works closely with the California Medical Association.

She says the situation could be especially dire for clinics that have a heavy load of low-income patients –- some may be forced to close: “There’s no way that a lot of those practices can keep their doors open. It simply does not pencil out,” she says. “It’s really, really scary.”

Doctors are also worried about having to pay back years’ worth of retroactive cuts, dating back to 2011 when they were first signed into law. The state was in financial turmoil then. But now the fiscal picture is much improved and clinics have been pressuring lawmakers to reverse the cuts. Democrats have drawn a budget blue print that does just that.

Gov. Jerry Brown is expected to release his budget later Thursday, and early indications are that he will rescind the retroactive cuts. Advocates are hopeful.

“California does have a surplus,” says Kathy Kneer, president and CEO of Planned Parenthood Affiliates of California. “I’m hoping that he’ll feel less need to continue cutting the Medi-Cal program and that we can just catch our breath.”

Doctors will be competing with advocates from a range of other causes, including education and the environment, who all want to see funds reinstated to previously slashed programs. If Brown does reduce or reverse the Medi-Cal cuts, the changes would have to be approved by the state legislature and the federal Centers for Medicare and Medicaid Services.

The Department of Health Care Services released enrollment numbers last week for Medi-Cal-eligible Californians who initially contacted the Covered California health benefit exchange.

The department said 143,608 people will likely receive Medi-Cal coverage as a result of contacting Covered California.

That’s about 40 percent of all applications completed through the exchange, said Anthony Cava, a spokesperson for DHCS.

“We are very pleased with this surge of interest and the momentum we are seeing in consumer awareness,” Cava said in a written statement.

The new Medi-Cal beneficiaries were generated between Oct. 1 and Nov. 20. The number is likely to increase substantially in the roughly four months before the enrollment period ends Mar. 31, 2014.

Medi-Cal currently covers 8.5 million Californians, about 22 percent of the state’s population. State health officials estimated one million to two million newly eligible Californians will sign up for Medi-Cal under the expansion, which is federally funded in full for the first two years. About 600,000 of those newly eligible are currently enrolled in the Low Income Health Program, and will make the switch to Medi-Cal when the expansion starts in 2014.

Not all Californians eligible for Medicaid sign up for Medi-Cal and that’s where the increased attention and visibility from the exchange could make a big difference, Cava said.

“DHCS is committed, along with its partner, Covered California to ensure that those who are uninsured and eligible can take advantage of the opportunity to gain health coverage through Medi-Cal or a Covered California health plan,” Cava said.

Enrollment of healthy people like them in insurance under the Affordable Care Act is key to offsetting the costs of older, less healthy buyers.

Brad Stevens is 54-years-old and not so invincible anymore. He has been uninsured for most of his adult life — “ever since about 24 when I finished college,” he says. “Basically, I’ve always tried to take care of myself and be healthy and exercise and eat right and take vitamins and that type of thing.”

During the three decades Stevens has spent without health coverage, there have been numerous attempts to curb the ranks of the uninsured in the U.S. Now, the Affordable Care Act is changing the nation’s insurance market.

Stevens, who lives in Lakeport, on the west shore of northern California’s Clear Lake, has plenty of company. Twenty percent of California’s population is uninsured; some 5 million people could gain coverage under the health law.

Over the years, Stevens wasn’t interested in the debate over how best to provide health care to the uninsured. He didn’t view it as an issue for him. “I’m the epitome of health, and so I didn’t have much concern. My health care was working out every day, eating right and taking care of myself,” he says.

But that began to change. One day eight years ago, while cycling on a country road in Lakeport, Stevens took a spill and separated his shoulder.

By then he had worked in a number of jobs, usually working with his hands. He’d been a building contractor, manager of a fruit warehouse and lately, a massage therapist. In pain for six months and with only $2,000 to his name, Stevens got medical help from the county.

That wasn’t the end of his health troubles. One day, he says, “Boom! I ended up with cancer, thyroid cancer.”

Because of the health care law, Stevens will qualify for Medi-Cal, California’s version of Medicaid, the federal program for low-income families and individuals. Before the health law, Medi-Cal was available only to children, pregnant women and the disabled. Now all low-income people in states that are expanding Medicaid will qualify. Stevens earns less than $15,000 a year in his struggling massage business.

Stevens says he is relieved that he won’t have to worry about being denied coverage for pre-existing conditions, another change made by the law.

Besides his separated shoulder and thyroid cancer, which is being controlled with medicine, there’s a history of multiple sclerosis in his family. In the past, he avoided getting tested for the disease out of fear that the results would make it impossible to qualify for insurance.

Stevens says he worries about his massage patients. “People are hurting, and they need help,” he says. “I don’t think Congress has a clue. Fifty-five-year-old people are falling apart. They can’t swing a hammer ’til they’re 70 or 80, like some congressman who sits at a desk and jaws.”

In the past, Stevens occasionally went to the county fairgrounds when a volunteer group offered free medical checkups. Now he’s anxious to sign up for Medi-Cal, although he hopes he won’t have any more health problems.

“I hope I don’t need to use it,” he says. “I’m thinking I’m going to get … peace of mind from it.”

]]>http://ww2.kqed.org/stateofhealth/2013/10/04/former-young-invincible-looks-forward-to-health-insurance-medicaid-obamacare-uninsured/feed/0BradStevens copyBrad Stevens used to think he didn’t need health insurance. (Sarah Varney/Kaiser Health News)Low-income California Children Among Least Likely to Get Dental Carehttp://ww2.kqed.org/stateofhealth/2013/06/25/low-income-california-children-among-least-likely-to-get-dental-care/
http://ww2.kqed.org/stateofhealth/2013/06/25/low-income-california-children-among-least-likely-to-get-dental-care/#commentsTue, 25 Jun 2013 18:07:48 +0000http://blogs.kqed.org/stateofhealth/?p=13395Continue reading Low-income California Children Among Least Likely to Get Dental Care→]]>Almost 60 percent of California children on Medi-Cal did not receive any dental care in 2011. (nmoira/flickr)

Young people who don’t get the routine dental care they need find themselves at a disadvantage, studies have shown: not just in overall health but also in school performance.

Now a study from the Pew Charitable Trusts finds that California is among the 10 states where low-income children are least likely to receive dental care.

Almost 60 percent of children with Medi-Cal did not receive any dental care in 2011, said co-author Jane Koppelman.

“What it means is that kids can have insurance, they can have (Medi-Cal), but it’s more like a hunting license than an entitlement,” says Koppelman, research director for the Pew Children’s Dental Campaign. “It’s a license to try to find a dentist who can give you care. And in a lot of areas that is quite a trial.”

Koppelman said there are a number of reasons why pediatric dentists who take Medi-Cal are few and far between. For one, some dentists don’t want to deal with the hassle factor that comes with being involved in a paperwork-intensive public program. But Koppelman also points to low reimbursement rates.

“Kids can have insurance, they can have (Medi-Cal), but it’s more like a hunting license than an entitlement. It’s a license to try to find a dentist who can give you care.”

Ellen Espejo, director of media and health policy at Children Now, agrees.

“Given that California has one of the lowest reimbursement rates in its Medicaid program, it’s unfortunately not surprising,” said Espejo.

In fact, the portion of kids on Medi-Cal who weren’t seen by a dentist in California increased between 2010 and 2011, from 57.7 percent to 58.6 percent.

“This is definitely an ongoing problem with the threat to escalate,” Espejo said. “The budget before the governor now has a 10 percent reimbursement rate cut that would affect dentists.”

There has been some good news for adults using Denti-Cal, the dental arm of Medi-Cal. Nonemergency dentist benefits were partially reinstated for the coming year after being cut out in 2009. But Espejo said for kids the issue is more than just coverage and having providers signed up. It’s about having providers that are also able and willing to work with kids.

“There are general dentists that accept Medi-Cal,” Espejo said. “But the issue from the children’s perspective is that these general dentists may not be well trained or staffed to see children.”

Getting children in the door early is key to the long-term benefits of dental care, said Nadereh Pourat, a professor at the UCLA School of Public Health.

“You want the kids to get early care to prevent cavities. They don’t get that and then they are set up for problems later on,” Pourat said.

Pourat said the fact that children are not being seen is all the more frustrating because it requires a relatively small outlay of money. ”When you talk about preventive care for children you’re talking about really inexpensive care … sealants and fluoride, and about teaching them how to clean their teeth,” she says.

Pourat said there is also an element to the story that raises questions about the factors that are necessary to make sure people actually receive health care.

“Coverage is supposed to be the No. 1 facilitator to access and here are all these kids not getting access,” said Pourat.

The intersection between coverage and access is at the heart of the Affordable Care Act. Pew study author Koppelman said the lack of dental access for low-income California children is important to keep in mind as the state faces a time when expanded private insurance coverage could mean even more competition for pediatric dentistry resources.

“The provider shortage is not a new story,” Koppelman said. “What’s new is that it’s not getting better, and it’s not getting better at a time when we’re going to see an influx of millions more children into the dental delivery care system.”

]]>http://ww2.kqed.org/stateofhealth/2013/06/25/low-income-california-children-among-least-likely-to-get-dental-care/feed/1Kids dentistAlmost 60% of California children on Medi-Cal did not receive any dental care in 2011 (nmoira/flickr)Oregonian Describes Life — and Health — After Winning Medicaid Lotteryhttp://ww2.kqed.org/stateofhealth/2013/05/03/oregonian-describes-life-and-health-after-winning-medicaid-lottery/
http://ww2.kqed.org/stateofhealth/2013/05/03/oregonian-describes-life-and-health-after-winning-medicaid-lottery/#commentsFri, 03 May 2013 22:26:52 +0000http://blogs.kqed.org/stateofhealth/?p=12536(Fred/Flickr)

For you wonks out there, Kaiser Health News has a fascinating Friday afternoon read for you.

With no money for better food, no money for good shoes to go on walks, no rain gear, no walkman for listening to music as a distraction while walking, change is harder.

To quickly recap, in a New England Journal of Medicine study researchers analyzed how 10,000 people who won Medicaid coverage have fared since they gained insurance. The highlights were: no apparent affect on physical health; rates of depression 30 percent lower than those without coverage; catastrophic out-of-pocket medical expenses essentially eliminated.

In his piece, Rau publishes excerpts from seven blogs, each with a different take on the study’s highly nuanced results. But he closes with something I hadn’t seen elsewhere: a view of the experiment by someone who says he was one of the winners of the Medicaid coverage. Rau found the post on the blog Robert’s Stochastic thoughts.

Here’s the post in its entirety:

I am one of the winners in the Oregon lottery [winners could get Medicaid]. Going from no insurance to insurance is very confusing. When you have no money every health question starts with “would I rather live with this problem and have electricity, or treat this problem and keep my milk in a cooler for a month or so?” Stepping back into healthcare was like hopping on a merry-go-round. The doctor wanted to do test after test to come up with baselines for me, and I had a hard time showing up at the lab, I hadn’t been going to the doctor to find out new things about what was wrong with me. A huge part of living without insurance is not thinking about your high blood pressure damaging your kidneys. It takes a while to change that. It took me 6 months to change my level of co-operation with my doctor, and she said I was faster than many. Most people got into the groove about their 2nd physical. Then we had year-to-year values for blood tests and weight and blood pressure. Those numbers getting better helped. I lost 40 pounds the first year, regained 15, and lost another 10 the next year. Now my doctor wants me to try for another 10 pound loss. I have gone from 3 blood pressure medicines to 1, and that’s at a half dose. This whole time my blood pressure stayed the same, but dropping 2 pills and keeping the same score is a health upgrade. My blood sugar is still pre-diabetic, but diabetes is a progressive disease. If you keep your blood sugar at the same level for 2 years, you are making progress with managing diabetes. The study would have found me to make no progress, but my doctor thinks I have improved.

The last point is that diabetes and cholesterol are both food-based diseases. The Oregon Medicaid project enrolled very poor adults, I think the income cutoff was much lower than the SNAP benefit limit. So none of us have access to unlimited fresh fruit and low fat meat. We still eat nothing but carbs for most meals.

The mental health benefits are enormous. Changing how you eat and exercise is hard for everyone, but most people can throw a bit of money at the problem and grease their way. With no money for better food, no money for good shoes to go on walks, no rain gear, no walkman for listening to music as a distraction while walking, change is harder.

What I would like to see is a study that shows the changes in these measurements over a 2 year period for people who have insurance. People with insurance for the last 20 years are not always improving their health, either.

So much in this post touches on the tough policy issues we’re facing today: health is about so much more than health care; it’s really hard to change habits and even harder if you’re poor; how mental health affects health. But that last line is really a zinger.

]]>http://ww2.kqed.org/stateofhealth/2013/05/03/oregonian-describes-life-and-health-after-winning-medicaid-lottery/feed/3welcometoOregonSign_FredFlickr(Fred/Flickr)Feds to States on Medicaid: Expand Fully or No New Fundinghttp://ww2.kqed.org/stateofhealth/2012/12/10/feds-to-states-on-medicaid-expand-fully-or-no-new-funding/
http://ww2.kqed.org/stateofhealth/2012/12/10/feds-to-states-on-medicaid-expand-fully-or-no-new-funding/#commentsTue, 11 Dec 2012 00:16:20 +0000http://blogs.kqed.org/stateofhealth/?p=9362HHS Secretary Kathleen Sebelius, shown here speaking at a conference in Washington last week. (Chip Somodevilla/Getty Images)

The Obama Administration handed down a key rule Monday on its health care overhaul having to do with Medicaid, or Medi-Cal in California. States must expand to the federally mandated 138 percent of poverty in order to receive matching funds for those newly eligible for the program.

Because the Supreme Court ruling in June had struck down the requirement that states participate or lose existing match funds, some states thought there might be flexibility in the expansion. But the answer to that question is a clear “no” as Secretary of Health and Human Services Kathleen Sebelius explained in a letter to governors.

In a briefing last week, California’s Health and Human Services Secretary Diana Dooley indicated she was waiting for guidance from the feds about the Medicaid expansion and might not expand to the full 138 percent limit.

In an email, a spokesperson for the state’s department of health and human services said staff is currently evaluating the new information and declined to comment further at this time.

Consumer advocates said it was good to have the matter settled. “We thought that it was the case,” Anthony Wright, Executive Director of Health Access told me in a phone call, “but it’s good for the federal government to provide clarity and hopefully this allows the states to move forward with all deliberate speed.”

It’s expected that more than four million Californians will be newly eligible for Medi-Cal. Under the Affordable Care Act, the federal government will pay 100 percent of the cost of those new eligibles from 2014 to 2017. After that, the match will phase down to 90 percent by 2020.

The so-called “fiscal cliff” is a package of automatic spending cuts and tax hikes set to kick in next month unless President Obama and Capitol Hill agree on a way to stop them.

Negotiations to avert the cuts are ongoing and both sides have exchanged offers. On one side, the president and congressional Democrats have said they will reduce spending on entitlements, including Medicare, if Republicans will agree to increase tax rates on the highest earners.

And on the other side, Republicans have agreed to more revenue — but by closing loopholes and eliminating some deductions. They oppose raising tax rates.

Here are answers to six questions about what could happen in health care before the end-of-year deadline.

Q: If no deal is struck, how would that affect Medicare patients as well as the hospitals and physicians and other providers who care for them?

A: Under the series of automatic spending cuts called “sequestration,” Medicare providers would be subject to an across-the-board 2 percent payment cut in fiscal 2013. That’s $11 billion. According to a September report from the Office of Management and Budget, hospitals would bear the largest share of the cuts, with payments reduced by about $5.8 billion.

Seniors would see no changes in their benefits.

Q: How does that 2 percent cut in payments to physicians affect the 27 percent cut in Medicare payments to doctors already scheduled to occur in January?

A: Physicians who accept Medicare patients would face the 2 percent cut on top of an already scheduled 27 percent reduction in January unless Congress steps in to stop it.

That payment formula was created in a 1997 deficit reduction law that called for setting Medicare physician payment rates through a formula based on economic growth. It’s known as the “sustainable growth rate” (SGR).

For the first few years, Medicare expenditures did not exceed the target and doctors received modest pay increases. But in 2002, doctors reacted with fury when they came in for a 4.8 percent pay cut. Every year since, Congress has staved off the scheduled cuts. But each deferral just increased the size – and price tag – of the fix needed the next time.

A deal on the SGR could be part of a “grand bargain,” if congressional fiscal cliff negotiators decide to include it. To that point, Obama’s offer to Republicans included $25 billion to stop the scheduled cut. Congress could also pass separate legislation to stop the cuts. Some doctors say that if Medicare reimbursements are further reduced they may stop accepting Medicare patients.

Q: If negotiators do reach a deal, what could that mean for Medicare?

A: It depends on how large a role Medicare plays in a broader deal. Some of the proposals include raising Medicare’s eligibility age to 67, asking wealthier Medicare beneficiaries to pay more for their coverage and paying Medicare providers less. All are complicated and many Democrats have said that they do not want to make changes that harm beneficiaries or shift costs from the government onto seniors. Republicans are insisting that entitlement savings play a large role in any deficit reduction deal.

Q: How is Medicaid affected, either way?

A: Medicaid does not face any automatic cuts starting Jan. 1. The Supreme Court’s ruling in June made the health law’s Medicaid expansion optional for states, so there’s concern that any reductions in federal Medicaid spending might make governors even more reluctant to expand the federal-state program.

Many Republicans, including GOP presidential nominee Mitt Romney and his running mate, Rep. Paul Ryan, R-Wis., favor changing Medicaid into a block grant, where states are given a set amount of money and more freedom to decide who is covered and what benefits they would receive. But the block grant concept is a non-starter with Obama and Democrats.

Q: If no deal is reached by Jan. 1, what happens to federal funding for medical research?

A: The National Institutes of Health would see a $2.5 billion reduction in 2013, which means that the agency would “have to halt or curtail scientific research,” according to the OMB analysis. Other agencies would see cuts, too. For example, the Centers for Disease Control and Prevention would face cuts of $490 million, and the Food and Drug administration would see reductions of about $318 million.

Q: If no deal is reached, what happens to health care for members of the military and veterans?

A: The TRICARE program for active members of the military system would also face an across-the-board 2 percent cut. The Veterans Affairs health system, however, is exempt from sequestration.

If Caroline Cunningham wakes up in her Studio City home on Wednesday morning to a President-elect Mitt Romney, she knows the first thing she will do. “I have to rush and get back surgery,” she says.

Cunningham, a 62-year-old mental health therapist with spinal stenosis, has health insurance coverage through a temporary program established for people with pre-existing conditions under the Affordable Care Act. The pre-existing condition insurance plans, mandated in every state and subsidized by the federal government, offer coverage to those deemed uninsurable.

But the high risk pools, as they are known, have an expiration date. They are slated to shut down in January 2014 when, under the federal health law, people with pre-existing conditions can buy plans from private insurers through newly created insurance exchanges.

If Romney follows through with his pledge to dismantle President Barack Obama’s signature domestic legislation and Congress is unable to quickly enact a meaningful alternative, Cunningham worries she will, once again, be uninsured. “I called the Romney campaign and asked them what they’re going to do,” said Cunningham. “I hope they wouldn’t dump us.”

Medicaid Expansion

More than any other state, California has wagered heavily on the Affordable Care Act. It has moved quickly to erect an insurance exchange and establish the high risk pool. It has also put federal consumer protections into state law.

In 2010, the state signed a $10 billion Medicaid waiver with the Obama administration that allowed counties from Democratic Los Angeles to Republican San Diego to enroll as many as 500,000 low-income adults into a ‘Medicaid-lite’ program — years ahead of the Medicaid expansion required by the act. Similar to the high risk pool, ‘Medicaid-lite’ — officially called the Low Income Health Plan — is a temporary measure until January 2014. That’s when California would open up its Medicaid program to millions of poor people, an expansion paid for largely by the federal government.

But if a Romney Administration follows through with its vow to undo the health law, that deadline could come and go without an expanded Medicaid program or a health insurance exchange in place.

“It’s the ballgame at stake,” said Anthony Wright, executive director of Health Access California, an advocacy group. “We go from the major reforms to a salvage operation.”

The various provisions in the health law and California’s Medicaid waiver were all designed to work in concert. “The fundamental design of health reform in California was a layering of stuff,” said Peter Harbage, a policy analyst who has advised Republican and Democratic administrations on health issues. “Phase one, phase two and phase three, and if one of the later phases doesn’t materialize, then people could be left without insurance.”

California’s health insurance exchange, ‘Covered California’

As for California’s nascent health insurance exchange, now called Covered California, spokesman Oscar Hidalgo said in an email, “We are moving forward with our mandate to implement the California exchange.”

The oversight board and staff of Covered California have been busy putting into place the state’s online insurance shopping portal and vetting the menu of a la carte insurance products. But there is widespread agreement that the online marketplace would falter if a Romney Administration were to cut off the federal subsidies aimed at helping working-class and middle-income individuals and families to buy coverage on the exchange.

Yet even in beleaguered California, there remain some who are optimistic that a Romney Administration would not signal the end of a comprehensive plan to deal with the uninsured.

Michael Cousineau, an associate professor of family medicine at the Keck School of Medicine at the University of Southern California and a long-time advisor to state and county officials on health care financing, said Romney’s preference for state control could mean his administration might allow California to extend its Medicaid waiver and coverage expansion of low-income adults. “The question is how much money would the federal government put into it?” said Cousineau.

But a new administration in Washington turning off the spigot is not the Golden State’s only worry. On Tuesday, Californians will weigh in on a ballot measure, Proposition 30, that would increase the state’s sales tax by .25 percent and raise income taxes on high-income earners. The initiative’s biggest backer is California Gov. Jerry Brown who has said if the measure fails, he will be left with an $8.5 billion budget hole. That deficit will largely be closed by cuts to public schools, Brown and Democratic lawmakers argue, since the legislature has already slashed $23 billion in funding for health and welfare services, criminal justice and other programs.

Still, health care leaders here say if Proposition 30 fails, and Obama holds onto his job and the Affordable Care Act, the state will nonetheless enter a grim era of budget austerity. In that scenario, where the state is likely to cut weeks off the school year for public school children, Brown might be unwilling, they say, to move ahead with California’s planned Medicaid expansion. “It would be very hard,” said Wright, “to move forward with anything that even costs a dime.”

Whatever the outcome on November 6th, officials in Washington will still have to deal with a looming “fiscal cliff” before the end of the year.

What’s coming is a perfect storm of expiring tax cuts, scheduled budget cuts, and various other spending changes scheduled to take place Jan. 1 unless Congress and President Obama (who, no matter what, will still be president until next Jan. 20) agree on a way to avert them.

As two of the largest spending items in the federal budget, the Medicare and Medicaid health programs are expected to play a role in how the deal gets done. Under the provisions of the law that created the budget deal Congress will attempt to undo, Medicare is subject to a two percent cut in provider payments, while Medicaid is exempt.

But two new studies and a proposed class action lawsuit settlement suggest a lot of dollar signs could change as lawmakers start to think about how to address the impending mess.

A proposed settlement in a long-running dispute between advocates for Medicare patients and the federal government is actually likely to increase Medicare spending — although how much remains unclear.

The suit was brought by the Center for Medicare Advocacy on behalf of a class of patients with chronic conditions. these patients had been denied Medicare coverage for home care, nursing home care or other services on the grounds that the patients’ conditions were not expected to “improve” with care.

The settlement — assuming it is approved by the judge in the case — means that “the Medicare Benefit Policy Manual will be revised to correct any suggestion that continued coverage is dependent on the beneficiary improving,” said the organization in a statement. The change is expected to affect as many as tens of thousands of beneficiaries with conditions ranging from multiple sclerosis to Parkinson’s to diabetes, arthritis, and heart disease.

But while it will boost spending for Medicare by preventing many of those patients from spending themselves into poverty, it could well end up saving money for Medicaid, which is jointly financed by the federal government and the states.

Total state Medicaid spending grew by an average of two percent in fiscal 2012, “among the lowest rates of growth ever recorded,” according to the study. By contrast, spending in fiscal 2011 rose by 9.7 percent.

Part of the slowdown was due to a recovering economy, which made fewer additional people eligible for the program, the survey found. Part was also due to states imposing their own cost controls on the program, in part stemming from the end of additional temporary federal funding that came as part of the 2009 stimulus law.

That spending could go down more – a lot more – if Mitt Romney is elected and implements his plan for Medicaid, according to yet another study out this week.

This one, commissioned by the Kaiser Family Foundation and done by researchers for the Urban Institute, looked at the potential impact of implementing the plan approved by the Republican-led House. That’s similar to the one Romney is proposing.

The study found that the combination of repealing the Affordable Care Act (which calls for a major expansion of Medicaid) and limiting federal payments for Medicaid could together reduce federal Medicaid spending by $1.7 trillion from 2013 to 2022. That represents a 38 percent cut in federal funding for the program.

The study estimated a range of how many people would lose coverage, depending on how states react. The estimates, however, range from a low of 31.3 million fewer people being covered to 37.5 fewer million people being covered.

It turns out Republicans and Democrats do have something they can agree on this election season – they’re worried about how to pay for long-term care when they or a family member can no longer live at home.

A new poll released Wednesday by The SCAN Foundation and the UCLA Center for Health Policy Research found that half of California voters say they’ll need long-term care for a close family member in the next few years, but won’t be able to afford it.

Anxiety over the cost of long-term care, like the price tag of a nursing home stay, is going up. The percentage of California voters who said they couldn’t afford more than three months of nursing home care increased to 73 percent from 66 percent in 2011, and 46 percent said they didn’t have the money to cover a single month in a nursing home, about $6,800 in California. For Latinos, the prospect of paying for long-term care is even more grim: nine in 10 Latino voters said they couldn’t afford more than three months of nursing home care and 86 percent couldn’t afford more than three months of part-time care at home.

Long-term care costs can surprise many families who expect Medicare to cover their needs. After a hospital stay, Medicare will pay for 100 days of nursing home care, but after that, families are on their own or are forced to spend down their assets to become poor enough to qualify for Medicaid. Latino voters in California, the poll found, were the most confused about Medicare: 31 percent assumed the federal program would pay for long-term, nursing home care – more than twice as many as white voters.

What is certain is that there will be many more people spending their golden years in the Golden State. Over the next two decades, the population of seniors aged 65 and older is projected to double to 8 million. And Californians want their state government in Sacramento to find a solution. The vast majority of Republicans (81 percent), Democrats (94 percent) and independents (85 percent), the poll found, said that despite the fiscal calamities in California, figuring out affordable options for long-term care should be a top priority.

The poll surveyed 1,667 registered California voters age 40 and older and was conducted by Lake Research Partners and Chesapeake Beach Consulting between Aug. 15-22, 2012.

The future of the nation’s largest health insurance program — Medicaid — hangs in the balance of the Supreme Court’s decision on the 2010 health law.

The state-federal program which covers 60 million poor and disabled people would be greatly expanded under the health law, adding 17 million more people starting in 2014.

But if the entire law is struck down, states for the first time since 2009 would be free to tighten eligibility and make it more difficult for people to apply. The law had barred such changes.

And under another scenario — if the justices declare unconstitutional just the law’s expansion of Medicaid — the entire program enacted in 1965 as part of President Lyndon B. Johnson’s Great Society agenda could be threatened, health experts say. Twenty-six states had challenged the expansion, arguing it was “unduly coercive” because they would lose all of their federal Medicaid funding if they refused to expand the program.

“Depending on how sweeping and broadly written the decision is, it could be the entire Medicaid program has been unconstitutional since 1965, but we didn’t know it,” said Sara Rosenbaum, a health policy professor at George Washington University.

Medicaid is the workhorse of the nation’s health system, covering 30 percent of all children, 70 percent of nursing home residents and 40 percent of all deliveries. But because of its byzantine eligibility rules, the program still covers fewer than half of the people with incomes under the poverty level, or $23,025 for a family of four.

“Depending on how sweeping and broadly written the decision is, it could be the entire Medicaid program has been unconstitutional since 1965, but we didn’t know it.”

Today, in all but four states, children in families with incomes under 200 percent of the federal poverty level are eligible for Medicaid or the Children’s Health Insurance Program. Yet coverage for adults varies greatly by state, and whether a person is pregnant, working, disabled or has dependent children.

The median income level for parents to be eligible for Medicaid is now 63 percent of the poverty level, or about $14,000 for a family of four. Eight states today offer full Medicaid coverage to adults without dependent children and 13 states offer limited Medicaid benefits to childless adults.

But under the law, eligibility will become simpler in 2014: All Americans with household incomes below 133 percent of the federal poverty level (about $31,000 for a family of four) would qualify.

The federal government would pay the full cost for those newly eligible for Medicaid though 2016, then states would gradually assume some costs, maxing out at 10 percent after 2019. Those costs are now more evenly split, with the federal government picking up approximately 57 percent and states paying the rest.

To help ensure enough doctors are willing to treat Medicaid patients, the health law also increases pay to primary care doctors to Medicare levels in 2013 and 2014 – an average reimbursement increase of about 34 percent, according to the American Academy of Family Physicians.

“If the law survives, Medicaid will grow and look much different in 2014 than it does today,” said Alan Weil, executive director of the National Academy for State Health Policy. “If the law goes, states would begin looking at rollbacks in eligibility.”